1、人工全髖關節置換術后脫位的原因分析和防治對策(一)    作者：黃炎，孔榮，方詩元，禹德萬，李守民，張彪【摘要】 目的探討人工全髖關節置換術后脫位的原因分析和防治對策。方法本科自2001年1月2006年12月行全髖置換術311例，對術后脫位15例患者進行回顧性分析，評價術后脫位的危險因素及防治對策。結果所有病例中術后6個月發生脫位15例(脫位率4.82%)，首次全髖置換術后脫位11例，脫位率4.00%，而全髖翻修術后脫位4例，翻修手術脫位率11.11%，兩者有顯著差異(P0.01)。首次全髖置換手術患者中，骨折組、側臥外展試驗陽性組、后外側入路組、髖臼假

2、體置于安全區外組，患者術后脫位率分別為6.04%、10.29%、4.52%、9.93%，均明顯高于對照組(P0.05)，而不同性別、年齡以及使用不同直徑股骨頭的患者中術后脫位率無明顯差異(P>0.05)。15例脫位中14例經保守治療后未再發生脫位。1例患者發生習慣性脫位，行全髖翻修后未再發生脫位。結論全髖關節置換術后脫位與是否翻修，術前疾病狀態，組織的肌力平衡，手術入路，假體位置的安放等因素有關，與患者性別、年齡以及假體設計無關。大多數脫位患者通過保守治療未再發生脫位。通過改進手術方式，正確安放假體位置，及在醫師指導下康復訓練等會降低人工全髖關節置換術后脫位率。 【關鍵詞】 全髖關節置換

3、術; 人工假體; 術后脫位; 原因Abstract: ObjectiveTo analyze and prevent postoperative dislocation after total hip replacement (THR). MethodAmong 311 cases of THR treated from Jan 2001 to Dec 2006, 15 developed dislocation. These cases were retrospectively reviewed and their risk factors were investigated.ResultS

4、ix months after THR, 15 patients (4.82%) had postoperative dislocation. Among them 11 had primary procedure and 4 had revision procedure. The dislocation rates were 4.00% and 11.11%,respectively. This difference was statistically significant (P0.01). Among patients with primary procedure, the disloc

5、ation rates of bone fracture subgroup, side-lying-abduction-test-positive subgroup, posterolateral-approach subgroup and prosthesis-malposition subgroup were 6.04%, 10.29%, 4.52% and 9.93%, respectively. These differences were statistically significant (P0.05) compared with the control groups. But t

6、here was no difference between the variables of gender, age and prosthesis's diameter. No redislocation was found in 14 patients after conservation treatment. Habitual dislocation was operatively revised in one patient.ConclusionThe causes of postoperative dislocation after THR are related with

7、primary or revision arthroplasty, disease status, the balance of soft tissue, the operative approach and the position of prostheses, but not related with gender, age and prosthesiss diameter. Most patients with dislocation may be cured by manipulative reduction.Dislocation rate can be significantly

8、decreased by improvement of operative approach, proper placement of prostheses and rehabilitation training under the guide of specialist doctor.Key words：total hip replacement; dislocation人工全髖關節置換(total hip replacement，THR)術后髖關節脫位是僅次于假體松動的第2大并發癥，目前報道THR后首次脫位率3.2%6.5%，翻修后的脫位率可高達7.4%11.4%1。本文對311例THR進

9、行總結分析THR后髖關節脫位的危險因素和防治對策。1 材料與方法1.1 臨床資料自2001年1月2006年12月行首次全髖置換術275例，男性103例，女性172例;平均年齡61歲(3883歲)，平均體重65 kg(4580 kg)。術前診斷股骨頸骨折149髖，股骨頭缺血性壞死51髖，髖關節骨關節炎43髖，其他疾病(髖臼發育不良，股骨頭術后翻修，強直性脊柱炎等)32髖。其中221例經后外側入路(Gibson入路)，54例經前外側入路(Harding入路)。采用直徑28 mm的股骨頭假體212例，直徑大于或小于28 mm的股骨頭假體63例。另外進行全髖翻修術36例。1.2 檢查方法1.3 療效標

10、準據Harris髖關節百分制評分標準，從包括疼痛、功能、畸形和關節活動度4方面對髖關節進行評價，90100分為優，8089分為良，7079分為中，小于70分為差。1.4 統計學處理采用SPSS統計軟件(11.0版)，組內比較采用x2檢驗，P0.05為差異有統計學意義。所有百分數保留兩位小數。2 結果本組病例術后隨訪時間：最短1.5年，最長7.5年，平均4.2年。2.1 術后脫位發生情況及相關危險因素分析本組病例術后6個月發生脫位15例，總脫位率4.82%。首次全髖置換術后脫位11例，脫位率4.0%，全髖翻修術后脫位4例，脫位率11.1%，兩者有顯著差異(P0.01)。其中，首次全髖置換術后脫位

11、的發生與患者的疾病狀態，手術入路，外展肌力大小，髖臼假體的位置等因素有關，而與患者年齡，性別，股骨頭假體直徑無明顯關系。圖1、2表1。2.2 術后脫位的治療及療效15例脫位患者均在腰麻下手法復位后患側髖“人字形”石膏固定6周，其中14例未再發生脫位。1例患者因假體位置不良發生習慣性脫位，后行全髖翻修術后未再發生脫位。所有患者隨訪6個月后，按Harris評分標準優10例，良5例，未見80分以下病例。3 討論3.1 THR術后髖關節脫位的原因3.2 THR術后脫位的治療對策3.3 THR術后脫位的預防方法【參考文獻】1 Demos HA,Rorabeck CH,Bourne RB，et al.In

12、stability in primary total hip arthroplasty with the direct lateral approachJ.Clin Orthop Relat Res，2001,393:168-180.2 Sanchez-Sotelo J,Berry DJ.Epidemiology of instability after total hip replacementJ.Orthop Clin North Am，2001,32:543-552.3 Weeden SH,Paprosky WG,Bowling JW.The early dislocation rate

13、 in primary total hip arthroplasty following the pos terior approach with posteriorsoft-tissue repair J.J Arthroplasty,2003,18:709-713.4 Ekelund A,Rydell N,Nilsson OS.Total hip arthroplasty in patients 80 years of age and olderJ.Clin Orthop Relat Res,1992,281:101-106.5 Levy BA,Berry DJ.Long-term sur

14、vivorship of cemented all-polyethylene acetabular components in patients > 75 years of ageJ.J Arthroplasty,2000,15:461-467.6 Hedlundh U,Ahnfelt L,Hybbinette CH,et al.Surgical experience related to dislocations after total hip arthroplastyJ.J Bone Joint Surg Br,1996,78:206-209.7 Ritter MA,Harty LD,Keating ME,et al.A clinical comparison of the anterolateral and posterolateral approaches to the hipJ. Clin Orthop Relat